GP-269 COMNIO OF MASSACHUSET
TS
t;.4 .011 DirmumENT OF INDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
vs Camoeec� BOSTON, Sb L iS 02111
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
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.(licensee/penninec)
with a principal place of business/residence ac
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do hereby certify, under the pains and penalties of perjury, that:
11 1 am an employer providing the following workers' compensation coverage for my employees working on this
job.
fnsurancc Company an
P Y • Policy Number
1-) -1 ani a sole proprietor and have no one working for me.
[) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below
who have the following workers' compensation insurance policies.
Name of Contractor Insurance Company/Policy Number
Name of Conuactor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
0 I am a homeowner performing all the work myself.
NOTE: Please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a
swelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generally
-orisidered to be employers under the Workers' Compensation Act(GL C. 152,sea. 1(5)),application by a homeowner for a license.
ar permit rmay evidence the legal status of ao employer under the Workers'Compensation Act.
wtdcrstand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage
ratification and that failure to secure coverage as required under Sermon 25A of MGL 152 can lead to the imposition of criminal penalties:misting of a fine of up to$1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
inn of S 100,00 a day against me. •
iigncd A@{�! day of 400C-
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
I DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential
Owners Name 1/2l9"l'/n caP7 e Owners Address /,�' i iG- %Ye. A� A..fiA'617—
Building Location /Y_CO C<g/Yt e #e Date
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New E Renovation Replacement n Plans Submitted ❑
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SUB-BSMT.
G BASEMENT i
1st FLOOR
2nd FLOOR .
3rd FLOOR _
117 d 4th FLOOR _
5th FLOOR\A _
6th FLOOR
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7th FLOOR _
8th FLOOR
Installing Company Name Check One: Certificate
HANK'S SOUTHEASTERN PROPANE
Address 795Artedaa Won S Corp.
City WORFALUA°Waip Code n Partner _
Business Telephone: G79 5' -2-0 n Firm/Co.
Name of Licensed Plumber or Gasfitter !`LA/ 6'a//6/
INSURANCE COVERAGE: Check
I have a current liability insurance policy or its substantial equivalent. Yes No ❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General
Laws,and that my signature on this permit application waives this requirement.
Check.One:
Owner ❑ Agent ❑
Signature of Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered) in above application are true and
accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued .
for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the eral Laws. ���
B y u' .. Type of License: Q�G'r� =f� i .
Sig tare of Licensed Plumber or Gasfitter
Title ❑ MASTER ,Q
itsq/Town ❑ JOURNEYMAN License Number C 6_��
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